Unethical and Ignorant Behavior of Pharmacists

Stephen Barrett, M.D.

Most pharmacists who work in retail pharmacies have a serious
potential conflict of interest. On the one hand, they are professionals,
expected to be knowledgeable about drugs and to dispense them
in a responsible and ethical manner. On the other hand, their
income depends on the sale of products. Before the FDA's OTC (Over-the-Counter)
Drug Review drove most of the ineffective ingredients out of OTC
drug products, few pharmacists protested or attempted to protect
their customers from wasting money on products that did not work.

Today nearly all pharmacies carry irrationally formulated dietary
supplements, and many stock dubious herbal and homeopathic products
in addition to standard drugs. Chain drugstores are more likely
to do so than individually owned stores. Hospital pharmacies are less prone to do so. In the late 1990s, some pharmacy trade publications—most notably the now-defunct Natural Pharmacist—suggested that "natural
products" offered opportunities to make up for prescription
drug revenues lost as a result of managed care and other cost-containment
programs. Two pharmacy suppliers aligned with this trend were The JAG Group of San Clemente, California [1] and HealthTrust Alliance,
of Lawrenceville, Georgia [2], both of which offered comprehensive programs through which pharmacists could market dietary supplements and herbal and homeopathic products to their customers. I thought that these programs were appalling because (a) few common ailments can be helped with dietary supplements or herbal products, (b) nutrient depletion related to drug use is not common, (c) homeopathic products are worthless, (d) pharmacists are not qualified or legally permitted to be "natural healthcare practitioners, and (e) recommending products for hundreds of ailments would be outside the
scope of pharmacy practice, constitute the illegal practice
of medicine, and violate state laws against theft by deception. As far as I can tell, neither of these programs is active today, but the percentage of pharmacists who sell dubious products has increased considerably.

In the mid-1980s, two dietitians examined the labels of
vitamin products at five pharmacies, three groceries, and three
health-food stores in New Haven. Products were considered appropriate
if they contained between 50% and 200% the U.S. RDA and no more
than 100% of others for which Estimated Safe and Adequate Daily
Dietary Intakes existed. Only 16 out of 105 (15%) of the multivitamin/mineral
products met these criteria [3]. Although current data on the percentage of irrational formulations in pharmacies is not available, every one I have ever visited carried lots of them.

Pharmacy compounding is another problematic area. Compounding is the creation of a drug product by mixing ingredients.
Compounding
has legitimate uses and is most often done honestly at physician
request. However, some pharmacies compound drugs that have little or no rational use, including some that are potentially dangerous and lack FDA approval [4]. Two such product categories are chelating agents [5] and bioidentical hormones [6], both of which have been the target of FDA warnings.

Widespread Ignorance

If asked directly whether an ineffective product is worthwhile,
most pharmacists will answer to the best of their ability. However, many surveys have shown that pharmacists are poorly informed about herbal products, many types of dietary supplements, and homeopathic products.

In 1985, reporters from Consumer Reports magazine
visited 30 drugstores in Pennsylvania, Missouri, and California.
The reporters complained of feeling tired or nervous, and asked
whether a vitamin product might help. Seventeen were sold a vitamin
product and one was sold an amino acid preparation. (None of the products had any ingredient that was effective against fatigue or nervousness.) Only 9 of
the 30 pharmacists suggested that a doctor be consulted [7].

In 1987, two pharmacy school professors sent a questionnaire
to 1000 pharmacists in the Detroit metropolitan area and received
197 responses. Among the 116 who identified their five most-common
reasons for recommending vitamins or minerals, 66 (56%) listed
fatigue and 57 (49%) listed stress [8]. (Neither reason is valid.)
Homeopathic products have no therapeutic value [9] But in response to a question about homeopathy, 27.4% said it was
"useful," 18.3% judged it "useless," and
54.3% "didn't know." [10]

A study published in 1993 found that 47% of pharmacy students
at two Philadelphia schools were taking supplements. The study
demonstrated that many of them mistakenly believed that supplements
could improve energy and relieve stress and that a year of school
had only a modest influence on these beliefs [11].

Among 533 Minnesota pharmacists who were asked whether they used or recommended one or more of 34 herbal or natural products, 282 (53%) reported that they had personally done so, 240 (45%) reported that they had recommended them to family members, and 432 (81%) reported that they had recommended them to patients. The most popular choices were echinacea, aloe, zinc, glucosamine, chondroitin, ginkgo biloba, garlic, melatonin, chromium picolinate, ginseng, and St. John's wort [12].
(Except for melatonin, these substances have little or no practical use.)

A study at the University of Minnesota School of Pharmacy published in 2006 found that only 26% of faculty members and 3% of senior PharmD students considered homeopathy ineffective and 23% of faculty members and 35% of students said they had no opinion [13].

Despite considerable effort, I have located no evidence that pharmacy educators generally perceive misbeliefs about ineffective products as a problem area and are trying to produce students who think clearly about these products.

What Happened to Ethics?

The most common reason is greed. Advertising creates a demand
that the pharmacist can supply and make a profit. "If I
don't sell them, they'll just go to my competition down the street,"
is a common response. Pharmacists are apparently more interested
in a sale than in the patient's welfare. . . .

Rather than just recommending a multivitamin to patients concerned
about obtaining enough vitamins in their diet, pharmacists should
offer sound nutritional advice or provide referrals to experts
in nutrition such as registered dietitians. [14]

Pharmacists are also the only recognized health professionals
who sell tobacco products, which cause more death and years of
lost life than any other consumer product. Although many pharmacies have stopped offering cigarettes, many others still carry them.

In March 1998, at a symposium sponsored by the Good Housekeeping
Institute, former FDA Commissioner David A. Kessler, M.D, J.D.,
sharply criticized the willingness of a neighborhood chain drugstore
to sell supplements whose labels made improper claims. Next to
the pharmacy counter, he had counted 26 displays with such claims
as: "targeted mind improvement," "advanced memory
and concentration formula," memory support complex,"
helps increase serotonin level," "immune enhancer,"
"leg health," "cartilage rejuvenation and repair,"
and "As featured in the book, 'The Arthritis Cure.'"
He told the symposium audience:

I wonder whether many pharmacists really have given up their
roles as health professionals, as pharmacists. Maybe they're
no longer in control of the store. Maybe they're just behind
the counter, and anything in front of that counter goes. But
it's time for that profession to take responsibility for what
it's selling. [15]

The code of ethics of the American Pharmacists Association (APHA) does
not state that pharmacists have a duty to prevent dubious products
from lining their shelves [16]. A few states have laws declaring it
illegal for pharmacists to sell ineffective products, but these
laws have never been applied to the sale of OTC products. In 1995,
the National Association of Boards of Pharmacy passed a resolution
critical of homeopathy. Though commendable, this resolution has
had no visible impact on pharmacy practice.

The American Society of Health-System Pharmacists (ASHP), which mainly represents pharmacists who work in hospitals and managed care programs, has issued a position statement on the use of dietary supplements which states (in part):

ASHP believes that the widespread, indiscriminate use of dietary
supplements presents substantial risks to public health and that
pharmacists have an opportunity and a professional responsibility
to reduce those risks. . . .

ASHP believes that the criteria used to evaluate dietary
supplements for inclusion in health-system formularies should
be as rigorous as those established for nonprescription drugs
and that the self-administered use of dietary supplements
during a health-system stay may increase risks to patients and
liabilities to health care professionals and institutions [17]

This statement is commendable, but I have seen no organized effort by pharmacists, their professional organizations, or their schools to raise the relevant educational or ethical standards.

W. Steven Pray, Ph.D., D.Ph., a professor at the Southwestern Oklahoma State University College of Pharmacy has concluded that pharmacists sell homeopathic products for three reasons: wilful ignorance, blatant dishonesty, and overwhelming greed. He also notes that the APhA
endorses homeopathic products by (a) permitting homeopathic sellers to rent booth space at its conventions, (b) providing proponents with a national forum that reaches APhA members, and (c) publishing book chapters and articles that fail to adequately criticize homeopathy [18].

In another article, Pray notes that the word "quackery" has virtually disappeared from the vocabulary of pharmacists and that:

Like other professions, pharmacy is under tremendous
external and internal pressure to accept and recommend
products lacking proof of safety and efficacy, and
not grounded in evidence-based medicine. Pharmacy colleges
should include a required course in unproven medications
and therapies. It should address the benefits of an
evidence-based approach to medicine in general and to
pharmaceutical care in particular. It should discuss the
ethical dilemma inherent in recommending products lacking
proof of safety and efficacy. When unproven systems
are taught (eg, homeopathy), they must be clearly labeled
as such and their departures from evidence-based medicine
clarified for students.

Instead, he reports how, for more than ten years, nearly every communication channel through which pharmacists receive information about dietary supplements, herbs, and homeopathic products has portrayed them more favorably than they deserve. To counter this, he urges pharmacy schools to provide the naked truth in a course that minces no words and even asks students to complain to the FTC about misleading product advertising [19].

The Bottom Line

I believe that pharmacists have as much of an ethical duty
to discourage use of inappropriate products as physicians do to
advise against unnecessary surgery or medical care. Very few pharmacists
do so. Pharmacy journal editors ignore this problem. Hospital-based
pharmacists generally exhibit a higher standard of practice, but
very few of them are speaking out about the problems described
in this article.

Pharmacists and their customers have millions of conversations per year about dietary supplements, herbs, and homeopathic products. Can you imagine what would happen to quackery in America if pharmacists discouraged inappropriate purchases of these products? Do you think that will ever happen?